Disease Dilemma: Risks and Realities

For Leon County Sheriff Larry Campbell, being vaccinated for smallpox wasn't a tough decision.

“It’d be kind of dumb for me to be asking other people to take it if I wouldn't take it,” he says.

But as first responders like paramedics and police officers are asked to take the shot. Some wonder whether it's worth the risk. With SARS and the threat of smallpox getting the media attention, some doctors, like Larry Deeb, think we need to be more realistic about threats to our health.

Remember the anthrax attacks and runs on Cipro in 2001? How about last year's West Nile concerns? Dr. Joe Mazziotta says sometimes the real risks get overshadowed by what's new.

“Certainly with west Nile virus in retrospect it seemed like whole lot of news came about that and very few people died. More people died from just about any other illness that you don't hear about,” he says.

Dr. Landis Crockett is division director of disease control with the Florida Department of Health. He thinks the extra attention for different threats is important.

The fact that we had anthrax circulating at post offices and killing people was aperfectly serious event. Public health event, national security event of greatest proportions. Likewise with west Nile. You know, people think they can take what mosquitoes are carrying lightly; the answer is they've never been able to do that.

Smallpox vaccine is a precaution we'll hopefully never need. But for Sheriff Campbell, prevention is worth a shot. From SARS and smallpox to influenza and chicken pox, one of the best sources for health information is the Centers for disease control.

A: Smallpox is a highly contagious virus that is spread from person to person, historically killing 30 percent of its victims. People can prevent infection if they are vaccinated within four days of exposure, before symptoms even appear; afterward, it is too late, and there is no known treatment. The last case of smallpox in the United States was in 1949. Routine vaccinations ended in 1972. That means that some 45 percent of the public is totally unprotected. People vaccinated decades ago may have some residual protection; health officials are not sure.

Q: Who will be offered the vaccine?

A: First, about a half million military troops. For civilians, those people most likely to encounter a highly contagious smallpox patient. That includes workers in hospital emergency rooms and people on special response teams who would investigate suspicious smallpox cases. About a half million civilians are expected to be offered the vaccine during this first stage.

In a second stage, vaccinations would be offered to all other health care workers plus emergency responders such as police, fire and emergency medical technicians. That is likely to total roughly 10 million people. Eventually, after enough vaccine is licensed by the Food and Drug Administration, the vaccine will be made available to all Americans.

Q: Is it mandatory?

A: For the military, yes. For civilians, no. Even in the middle of a smallpox attack, there are no provisions to force civilians to be vaccinated. People exposed to the disease who refuse to be vaccinated could be quarantined.

Q: Wasn't smallpox wiped out?

A: In 1980, the disease was declared eradicated worldwide. All samples of the virus were to have been destroyed except those held by special labs in Atlanta and Moscow. Experts fear some of the Russian sample could have escaped to hostile nations.

Q: Does Iraq have the virus?

A: U.S. intelligence officials believe Iraq has a small amount of smallpox left over from the last outbreak in the 1970s. U.N. inspectors have not singled out smallpox as a threat.

Q: Why not just vaccinate everyone right now?

A: The vaccine itself, made with a live virus called vaccinia, carries rare but serious risks. Based on studies from the 1960s, experts estimate that 15 out of every million people vaccinated for the first time will face life-threatening complications, and one or two will die. Reactions are less common for those revaccinated.

For the approximately 130 million Americans never vaccinated, experts would expect nearly 2,000 to face life-threatening complications and 125 to 250 of them to die. For about 158 million people being revaccinated, experts expect nearly 800 life-threatening complications and about 40 deaths.

Q: What sort of reactions and complications?

A: Typical reactions include sore arms, fever and swollen glands. In an experimental trial under way in Nashville, Tenn., about 10 percent of people experienced extreme discomfort, with fatigue, fever, loss of appetite and other flu-like symptoms that lasted a day or two.

The most common serious reaction comes when vaccinia escapes from the inoculation site, often because people touch the site and then touch themselves or someone else. The virus transferred to the eye can cause blindness.

More deadly is encephalitis, which can cause paralysis or permanent neurological damage. Also fatal though very rare: progressive vaccinia, where the vaccination site does not heal and the virus spreads, eating away at flesh, bone and gut.

Q: Who is at greatest risk of complications?

A: People with weak immune systems — those with HIV, cancer and transplanted organs — face much greater risk, as do pregnant women. People with eczema risk a serious, permanent rash.

Q: How do these side effects compare with other vaccines?

A: Smallpox vaccine is more dangerous than any other.

By comparison, the measles-mumps-rubella shot can cause reactions including anaphylaxis, marked by swelling inside the mouth and difficulty breathing. But just 11 cases of anaphylaxis have been reported since 1990, out of more than 30 million vaccinations, and no one has died.

Q: If the vaccine is effective four days after exposure, why not just vaccinate after an attack?

A: Delivering mass vaccinations within days is incredibly complicated, and an attack would be much less deadly if there is more vaccination now. Planning is also under way for post-attack vaccinations.

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